Responsible for maintaining resident medical records in accordance with state and federal regulations, professional standards of practice, and company policies and procedures. This role ensures the accuracy and completeness of resident records from pre-admission through post-discharge.
Key responsibilities include:
- Managing resident health information to ensure records remain accurate, complete, current, confidential, and compliant with HIPAA and applicable regulations
- Ensuring accurate diagnostic coding to support appropriate billing, accounts receivable improvement, and cash flow
- Collecting, coding, indexing, filing, and retrieving medical records
- Performing ICD coding and creating medical records for all new admissions
- Conducting monthly audits for admissions, discharges, and routine quality assurance
- Reviewing records for compliance with documentation standards, physician visits, timeliness, and other regulatory requirements
- Auditing admissions, discharges, changes in condition, and other pertinent records throughout the resident stay
- Performing other duties as assigned
Requirements & Qualifications
- RHIA or RHIT credential preferred
- Minimum of 2 years of experience in medical records in a skilled nursing facility or healthcare-related field
- Experience with ICD coding preferred
- Knowledge of medical terminology, laws, and regulations as they relate to long-term care
- Effective communication skills to work with residents, families, staff, physicians, consultants, providers, governmental agencies, and community members
- Professional appearance and demeanor
Location
New Mexico, US
Employment Type
Full-time
Experience Level
Entry Level
Remote work allowed
No
Posted
1 week ago